JR Davis Construction Health Benefit Plan — Buy-Up Plan: Medical Schedule of Benefits
This document is the Medical Schedule of Benefits for the JR Davis Construction Health Benefit Plan Buy-Up Plan, effective April 1, 2026. It outlines covered medical services, associated cost-sharing (copayments, coinsurance, and deductibles), and applicable limits for both Cigna PPO Network (in-network) providers and Non-PPO (out-of-network) providers. The plan is administered by Preferred Benefit Administrators with member concierge care provided by Karias Health. Members should refer to the Medical Plan Document and Summary Plan Description for full details of coverage.
Effective April 1, 2026
Document Link : Visit the document here
Table of Contents
- Plan Financial Summary
- Medical Benefits — Detailed Schedule
- Pre-certification Requirements
- Prescription Drug Benefits
- Preventive Care & Routine Services
- Contact Information
1. Plan Financial Summary
| Financial Detail | Cigna PPO Network Providers | Non-PPO Providers |
|---|---|---|
| Medical Plan Deductible | $1,500 per Individual / $4,500 per Family | $5,000 per Individual / $10,000 per Family |
| Prescription Drug Deductible | $300 per Individual / $300 per Family | N/A |
| Plan Coinsurance | Plan pays 70% of covered expenses | Plan pays 50% of Reasonable & Allowed Amount |
| Out-of-Pocket Maximum | $5,000 per Individual / $10,000 per Family | $10,000 per Individual / $20,000 per Family |
| Lifetime Maximum Benefit | Unlimited | Unlimited |
Deductible Notes:
- PPO and Non-PPO deductibles do not combine.
- The Calendar Year deductible does NOT include pre-certification penalties, non-covered expenses, or charges in excess of Reasonable & Allowed charges.
- If enrolled for family coverage, each family member must meet their own individual deductible until the overall family deductible has been met.
Out-of-Pocket Maximum Notes:
- PPO and Non-PPO Out-of-Pocket maximums do not combine.
- The Out-of-Pocket Maximum includes Medical & Prescription Drug Calendar Year deductibles, Member Coinsurance, Medical & Prescription Drug Co-payments.
- Pre-certification penalties, non-covered expenses, and charges in excess of Reasonable & Customary charges do not accumulate towards the Out-of-Pocket Maximum.
- If enrolled for family coverage, each family member must meet their own individual Out-of-Pocket maximum until the overall family Out-of-Pocket maximum has been met.
2. Medical Benefits — Detailed Schedule
| Service | Cigna PPO Network Providers | Non-PPO Providers | Notes / Limits |
|---|---|---|---|
| Alcohol & Substance Abuse Treatment | Office Visit: $25 Co-payment; not subject to deductible. Hospital Clinic Visit: 70% Coinsurance; subject to deductible. Partial Hospitalization / Intensive Outpatient Treatment: 100% of covered expenses; not subject to deductible (includes Physician visits). Inpatient Hospitalization: 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Precertification is required for Inpatient admissions and Partial Hospitalization / Intensive Outpatient Treatment. |
| Allergy Injections & Testing (includes office visits & serum) | $25 Co-payment per visit; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Ambulance Services | 70% Coinsurance; subject to In-Network Calendar Year deductible. | 70% Coinsurance; subject to In-Network Calendar Year deductible. | Limitations apply; refer to Plan for details. |
| Autism Spectrum Disorders Treatment | Benefits are based on services provided. | Benefits are based on services provided. | Pre-certification is required for ABA; limitations apply. Benefit limits do not apply to occupational, physical, and speech therapies for treatment of autism spectrum disorders. Includes habilitative and rehabilitative care, Applied Behavior Analysis (ABA), pharmacy care, psychiatric care, psychological care, therapeutic care, and social work services. |
| Birthing Center | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Cardiac Rehabilitation (Phase 1 & 2 only) | $50 Co-payment; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Chemotherapy & Radiation Therapy | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Requires Pre-certification. |
| Chiropractic Services / Spinal Manipulation | $50 Co-payment; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Limited to 26 visits per Calendar Year. |
| Clinical Trials | Benefits are based on services provided. | Benefits are based on services provided. | Includes routine services during Approved Clinical Trials. Limited to routine Covered Services under the Plan, including Hospital visits, laboratory, and imaging services. |
| Dental / Oral Services (excludes excision of impacted wisdom teeth) | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Diabetes Self-Management Training & Education | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Dialysis / Hemodialysis | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Durable Medical Equipment | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Pre-certification is required for insulin pumps and supplies, and equipment in excess of $2,500 and for Out-of-Network providers. |
| Early Intervention Services (up to age 3) | $25 Co-payment; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Emergency Room Services (includes Facility, Lab, X-ray & Physician services) | 70% Coinsurance; subject to deductible. | Emergency Care: 70% Coinsurance; subject to In-Network Calendar Year deductible. Non-Emergency Care: 50% Coinsurance; subject to deductible. | — |
| Family Planning | For Women: 100% of covered expenses; not subject to deductible. For Men: 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Genetic Counseling, Testing & Related Services | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Pre-certification is required. Pre-certification is not required for BRCA Testing. |
| Home Health Care | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Pre-certification is required. Limited to 20 visits and 16 hours per day per Calendar Year. |
| Hospice Care (Inpatient / Outpatient) | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Pre-certification is required. |
| Hospital Services (Inpatient) | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | All Inpatient Hospital admissions require Pre-certification. |
| Hospital Services (Outpatient) | Clinic Services: 70% Coinsurance; subject to deductible. Outpatient Department: 70% Coinsurance; subject to deductible. Pre-admission Testing: 70% Coinsurance; subject to deductible. Outpatient Surgery in Hospital / Ambulatory Surgical Center: 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Refer to Pre-certification requirements. |
| Injectables | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Pre-certification is required. |
| Learning Deficiencies, Behavioral Problems & Developmental Delays | $25 Co-payment per visit; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Maternity Care | Physician delivery charges, prenatal/postpartum care, including planned home births: 100% of covered expenses; not subject to deductible. Inpatient Hospital charges: 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Refer to Newborn Care for newborn benefits. Refer to Birthing Center for benefits, if applicable. |
| Medical & Enteral Formula (includes metabolic formula) | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Requires Pre-certification. |
| Mental Health Services | Office Visit: $25 Co-payment; not subject to deductible. Hospital Clinic Visit: 70% Coinsurance; subject to deductible. Partial Hospitalization / Intensive Outpatient Treatment: 100% of covered expenses; not subject to deductible (includes Physician visits). Inpatient Hospitalization: 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Precertification is required for Inpatient admissions and Partial Hospitalization / Intensive Outpatient Treatment. |
| Newborn Care (includes Physician visits & circumcision) | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Orthotics (includes foot orthotics) | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Outpatient Imaging (includes MRI, CT & PET Scans) | $500 Co-payment per scan. Contact Karias Health prior to imaging to determine if you are eligible for a $0 Co-payment. | 50% of Reasonable & Allowed amount; subject to deductible. | Pre-certification is required. |
| Outpatient X-Ray & Laboratory Services (Outpatient Hospital & Independent Facility) | Diagnostic X-Rays: $100 Co-payment per visit; not subject to deductible. Laboratory: 100% of covered expenses; not subject to deductible. All other diagnostic tests: $100 Co-payment per visit; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Outpatient Therapy Services | $50 Co-payment per visit; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Requires Pre-certification after 13 visits. Combined Outpatient Therapy maximum benefit of 25 visits for Physical Therapy, Speech Therapy, and Occupational Therapy due to Illness or Injury. |
| Physician Hospital Visits | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Physician Office Visits (includes all related charges billed at time of visit) | Teladoc Virtual Visit: $0 Co-payment. Primary Care: $25 Co-payment; not subject to deductible. Specialist: $50 Co-payment; not subject to deductible. Urgent Care Facility / Walk-in Clinic: $55 Co-payment; not subject to deductible. Virtual Provider visits: Paid based on services provided. | 50% of Reasonable & Allowed amount; subject to deductible. | Pre-certification is required for on-going wound care. |
| Podiatry Care | $50 Co-payment per visit; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Prosthetic Appliances | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Refer to Durable Medical Equipment benefit for Pre-certification requirements. |
| Respiratory Therapy | $50 Co-payment per visit; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Second Surgical Opinion | Primary Care: $25 Co-payment; not subject to deductible. Specialist: $50 Co-payment; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| Skilled Nursing Facility, Extended Care Facility & Rehabilitation Hospital | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Requires Pre-certification. Combined Calendar Year maximum benefit of 60 days. |
| Surgical Procedures | Inpatient Hospital Surgery: 70% Coinsurance; subject to deductible. Outpatient Hospital / Ambulatory Surgical Center: 70% Coinsurance; subject to deductible. PCP Office: Included in $25 office visit Co-payment. Specialist Office: Included in $50 office visit Co-payment. | 50% of Reasonable & Allowed amount; subject to deductible. | Pre-certification is required for Outpatient surgery in a Hospital or Ambulatory Surgical Center. |
| Temporomandibular Joint Disorders (TMJ) Treatment | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Requires Pre-certification. |
| Transplant Benefits | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Requires Pre-certification. Managed through Cigna's LifeSOURCE Transplant Network. Includes transportation, food & lodging expenses to a maximum benefit of $10,000 per transplant procedure. |
| Urgent Care Facility & Walk-in Clinic | $55 Co-payment; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
| All Other Covered Medical Expenses | 70% Coinsurance; subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | — |
3. Pre-certification Requirements
Pre-admission certification is mandatory for all inpatient and outpatient facility-based services. This includes all hospital admissions and all services at a hospital, surgical center, outpatient facility, or dialysis center. Emergency hospital admissions must be approved within 48 hours.
Services requiring pre-certification:
| Service |
|---|
| All Inpatient Hospital Admissions |
| All Outpatient Hospital Based Services |
| Applied Behavior Analysis (ABA) Therapy |
| Chemotherapy & Radiation Therapy |
| DME in excess of $2,500 and DME from Out-of-Network Providers |
| Genetic Counseling, Testing & Related Services |
| Helmets & Knee Braces (orthotics) |
| Home Health Care |
| Inpatient Hospice Care |
| Injectables in excess of $1,500 |
| Medical & Enteral Formula |
| Outpatient Imaging |
| Outpatient Therapy Services after 13 visits |
| On-going wound care |
4. Prescription Drug Benefits
Prescription Drug Calendar Year Deductible: $300 per Individual / $300 per Family
Important Notes:
- Tobacco cessation products are covered at 100%; Deductible waived.
- Preventive Care drugs are not subject to the Prescription Drug Deductible.
- Prescriptions purchased from Out-of-Network Pharmacies are not eligible for reimbursement by the Plan.
- See Covered Services section for coverage requirements related to specialty drugs.
Retail Pharmacy Program (30-day supply maximum)
| Drug Tier | Co-payment | Deductible |
|---|---|---|
| Generic drugs | $10 Co-pay | Deductible waived |
| Preferred Brand drugs | $60 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $100 Co-pay | After Prescription Drug Calendar Year deductible |
Retail Maintenance Pharmacy Program (90-day supply maximum)
| Drug Tier | Co-payment | Deductible |
|---|---|---|
| Generic drugs | $25 Co-pay | Deductible waived |
| Preferred Brand drugs | $150 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $250 Co-pay | After Prescription Drug Calendar Year deductible |
Mail Order Pharmacy (90-day supply maximum)
| Drug Tier | Co-payment | Deductible |
|---|---|---|
| Generic drugs | $25 Co-pay | Deductible waived |
| Preferred Brand drugs | $150 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $250 Co-pay | After Prescription Drug Calendar Year deductible |
Specialty Drugs — Retail & Mail Order (30-day supply maximum)
| Drug Tier | Co-payment | Deductible |
|---|---|---|
| Generic drugs | $25 Co-pay | Deductible waived |
| Preferred Brand drugs | $150 Co-pay | After Prescription Drug Calendar Year deductible |
| Non-Preferred Brand drugs | $250 Co-pay | After Prescription Drug Calendar Year deductible |
5. Preventive Care & Routine Services
Routine Colonoscopy
| Cigna PPO Network Providers | Non-PPO Providers | Notes |
|---|---|---|
| 100% of covered expenses; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Age/frequency limitations apply. |
Routine Mammogram
| Cigna PPO Network Providers | Non-PPO Providers | Notes |
|---|---|---|
| 100% of covered expenses; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. | Age/frequency limitations apply. |
Routine Well Adult Care (Age 18 and above)
| Cigna PPO Network Providers | Non-PPO Providers |
|---|---|
| 100% of covered expenses; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. |
This routine benefit includes, but is not limited to, physician charges for an annual routine examination, routine x-rays and laboratory, immunizations, and the following routine services:
| Covered Routine Service |
|---|
| Immunizations |
| Fasting lipoprotein profile (cholesterol screening) |
| Annual Prostate Specific Antigen (PSA) screening |
| Tobacco use screening and cessation interventions |
| Fasting blood sugar screening (for diabetes mellitus) |
| Blood pressure screening |
| Obesity screening and counseling |
| Annual colorectal screening |
| BRCA genetic counseling and testing |
| Statin preventive medication |
| Bone Mineral Density (BMD) screening (once every 24 months) |
| Women's Health Services: pelvic exam & Pap test; screening for gestational diabetes; DNA Testing; HPV (Human Papillomavirus); counseling for sexually transmitted infections; counseling & screening for human immunodeficiency virus; screening & counseling for interpersonal and domestic violence; breastfeeding support & supplies; sterilization; and contraceptive methods & counseling. Limitations may apply. |
A complete list of covered ACA mandated routine services for women / adults is available at: https://www.healthcare.gov/coverage/preventive-care-benefits/
Routine Well Child Care (Birth through age 17)
| Cigna PPO Network Providers | Non-PPO Providers |
|---|---|
| 100% of covered expenses; not subject to deductible. | 50% of Reasonable & Allowed amount; subject to deductible. |
Includes Office Visit charges, immunizations, laboratory blood tests, developmental screening, behavioral assessments, routine vision screening & hearing screening for newborns.
A complete list of covered ACA mandated routine services for children is available at: https://www.healthcare.gov/coverage/preventive-care-benefits/
6. Contact Information
| Resource | Details |
|---|---|
| Claims Administrator | Preferred Benefit Administrators, PO Box 916188, Longwood, FL 32791-6188 |
| Claims Phone | 407-786-2777 or 888-524-2777 |
| Claims Website | www.PreferredTPA.com |
| Member Concierge Care | Karias Health |
| Concierge Phone | 888-832-0354 |
| Concierge Website | www.kariashealth.com |
| Locate Cigna PPO Providers | www.Cigna.com |
This article is based on the JR Davis Construction Health Benefit Plan Buy-Up Plan Medical Schedule of Benefits effective April 1, 2026. Members should refer to the Medical Plan Document and Summary Plan Description for complete details of coverage.